Mornin

g
Report
Monday , August
6th,2012

Supervisor :
dr Sabar P Siregar Sp.Kj
I.Patients Identity
Name : Mrs. D
Age : 60 years old
Gender : Maleale
Address : Kebumen
Occupation : No Occupation
Marriage status: Married
Religion : Islam
Last education : SLTP (Junior High school)

Alloanamnesis
Name : Mr. S
Age : 35 years old
Relation : son
II.Chief complaint

Patient got angry

easily since a week
ago
Presenting illness
A week ago
Got angry easily when people talked bad things about
him. The patient broke many things in his house.
Sleepless. The patients sleep only for 3o minutes until
two hours a day.
The patients always spend his money to buy many
things even it is not useful for him, and the patient liked
to give everything to others.
The patient liked to make a coffee or tea but the patient
never drink it and did it again and again.
 The patient take a bath for more than two
times a day and like to change his clothes for
many times a day.
The patient was always well-dressed everyday
even though the patient didnt go anywhere.
The patient believes that he has a lot of
capability that make him count faster than a
calculator, and the patient has a power like a
doctor.
The patient admitted that the patient had
electrical engineering school, and the patient
believes that the patient is an engineer.
 The patient heard a voice through his
ears which says that the patient is a
loser.

Allof these symptoms occur together

with cough.
HISTORY OF PAST ILLNESS
 History of Personal Life
PRENATAL AND PERINATAL HISTORY

No valid data concerning medical conditions

during the mothers pregnancy.
No valid data concerning abnormalities
regarding patients birth and birth conditions.
Early Childhood Phase (0-3 years old)
Psychomotoric
There was no valid data on the patients growth and
development such as: first time lifting the head, rolling over,
sitting, crawling, standing, walking-running, holding objects in her
hand, putting everything in her mouth, holding objects in her
hand
Psychosocial
There was no valid data on which age patient started smiling
when seeing another face, startled by noises, when the patient
first laugh or squirm when asked to play, nor clapping hands with
others.
Communication
There was no valid data on when patient started saying words
like mom or dad, or when she started talking.
Early Childhood Phase (0-3 years old)

Emotion
There was no valid data of patients reaction when playing,
frightened by strangers, when starting to show jealousy or
competitiveness towards other and toilet training.
Cognitive
There was no valid data on which age the patient can follow
objects, recognizing her mother, recognize her family members.
There was no valid data on when the patient first copied sounds
that were heard, or understanding simple orders.
Intermediate Childhood (3-11 years old)
Psychosocial
There was no valid data
Psychomotor
No valid data on when patients first time riding a tricycle or bicycle, if patient
ever involved in any kind of sports.
Communication
There was no valid data regarding patients ability to make friends in school,
and how many friends patient have during her schooling period.
The patient begin to talk too much
Emotional
No valid data on patients adaptation under stress, any incidents of bedwetting
were not known.
Cognitive
No valid data on patients achievement in school, how well patients
performance at school
Late Childhood & Teenage Phase
Emotion
There was no valid data of patients reaction when playing,
frightened by strangers, when starting to show jealousy or
competitiveness towards other and toilet training.
Cognitive
There was no valid data on which age the patient can follow
objects, recognizing her mother, recognize her family members.
There was no valid data on when the patient first copied
sounds that were heard, or understanding simple orders.
 Adulthood
Educational and Occupational History : Stopped at junior high school, the patient
Worked as a labor and quit from his job because of his age.

Relationship status : Had a wife, marriage for 37 years and the patients have
a good relationship with his wife.

Legal History :Never had been arrested or caught by police.

Social Activity : Has many friends,

Current Situation : lives with his wife and his daughter family

Religious History : pray 5 times a day

Family History

Currently the patient lives with his wife

and his daughters family. No family
history about psychiatry illness.
Psychosexual history
Patient
psychosexual history is
appropriate of his gender and attracted
to woman
Genogram

Man with presenting

symptoms
Man
Woman
Progression of Ilness
sympto
m

Jan 2012 Sept2012

Role function
Mental State
Appearance :
Man, appropriate according to age, well-
dressed
State of Consciousness
Clear
Behaviour Command automatism
Hypoactive Acathysia
Hyperactive Tic
Echopraxia Somnabulism
Catatonia Psychomotor agitation
Active negativism Compulsive
Cataplexy Ataxia
Streotypy Mimicry
Mannerism Aggresive
Automatism Impulsive
Abulia
 ATTITUDE
Infantile
Non-cooperative Distrust
Indiferrent
Labile
Rigid
Apathy
Passive negativism
Tension Stereotypy
Dependent Catalepsy
Active Cerea flexibility
Passive
Emotion
Disturbance of perception

Derealisation (-)
 Thinking
thought progression
Thought Process
content of thought
Idea of reference
Delusion of magic-mistic
Preokupasi Delusion of control
Obsesi Delusion of influence
Fobia Delusion of passivity
Delusion of persecution Delusion of perception
Delusion of suspicion Thought of echo
Delusion of envious Thought of insertion/withdrawal

Delusion of hipokondri Thought of broadcasting

Delusion of grandiose
Thought form
Form of Thought
Realistic
Non Realistic
Dereistic
Autistic
attention
Easyto get patient attention and
easy to maintain.
SENSORIUM and cognition
Level of education : enough
General knowledge : enough
Orientation of time : good
place : good
people : good
Working/short/long memory : enough
Writing and reading skills : enough
Visuospatial : enough
Abstract thinking : good
Ability to self care : good
PHYSICAL EXAMINATION
Internal Status
Conciousness : compos mentis
Vital sign:
Blood pressure : 150/100 mmHg
Pulse rate : 76x/mnt
Temperature : afebris
RR: : 20x/mnt
 Head : normocephali
Eyes : anemic conjungtiva -/-, icterik sclera
-/-, pupil isocore
Neck : normal, no rigidity, no palpable
lymphnode
Thorax:
Chor : S1 and S2 Sound and normal
Lung : vesicular sound, wheezing -/-, ronchi +/-
Abdomen : Pain - , peristaltic normal, thympany sound
Extremity : Warm acral, capp refill <2
Neurological status
Motoric : not tested
Physiological reflex : not tested
Pathological reflex : not tested
SIGNIFICANT FINDING
RESUME
Differential Diagnose
F06.30 Organic Manic Disorder
F30.2 Mania with psychotic symptoms
F25.1 Schizoafective Dissorder, Manic
Type
Multiaxial Diagnose
Axis I : F06.30 Organic Manic
Disorder
Axis II : none
Axis III : hypertension stage I, suspect

bronkopneumonia
Axis IV : unclear
Axis V : GAF 40-31
Therapy
Hospitalized
X-ray examnination
Farmacology
- Tab Haloperidol 2x 5mg PO
- Litium carbonat 1x400 mg PO
- Tab Amoxicillin 3x500 mg PO
- Tab Ambroxol 3x 30mg PO
Family education
Explainto his familyabout this patient
mental disorder
Describes stepsoftreatment
Family must maintain the patients drugs
consumption and routine doctor
consultation, so it will increase the efficacy
of treatment
Family must keep in touch with patient
intensively, so the patient will not feel
lonely.
 Ad vitam : Ad Bonam
Ad functionum : dubia Ad malam
Ad sanationum : dubia Ad malam
Thank you